GW1-2022-01465_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD For Internal U ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Austin Fowler FROM 11> DFs(RuTlm
Well Contractor Name
4366A c� Q �Q?t' r(. ft.
NC Well Contractor Certification Number '�*` 15.INNER CASING OR TUBING ermal daed�
FROMTO DIAMETERI T11MESS MAII KI Al
CATLIN Engineers and Scientists 0 rt. 21t.1 2 in.1 Sch. 40 1 PVC
Company Name 16.OUTERCASING for multi-cased wells OR LINER ifa ieable
FROM TO DI:\ME1ER THI(KNESS NIAITRL11
2.Well Construction Permit#: N/A in.
List all applicable well permits(i.e.f'n,nn Sale, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAM111-1tR SLOF,1/1 T111(K\1" n ri v
❑Agricultural ❑Municipal/Public 2 ft. 17 n. 2 in. Slot.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) e. n. -in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM 1() MATERIAL EMPLACEMENT NETIJOD&AMOUNT­
OIrrigation It. rt.
Non-Water Supply Well: nc -
0 5 1 5 a. Bent.Pellets Surface Pour
0Monitoring ❑Recovery
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To %LaTERIAL EMPLACE%ENT NETHOO
1.5 ft. 17 Medium Sand Torpedo Sad
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control o. a.
20.DRILLING LOG attach additional sheets if a
❑Geothermal(Closed Loop) ❑Tracer FROM 10 1
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) It. ft.
4.Date Well(s)Completed: 12/14/21 Well ID#: MW-06R h. e. C t��n. �O
5a.Well Location:
rt. ,
NCDEQ-Ed's Village Open Air Market N/A
Fac i l ax Owner Name Facility ID#(if applicable)
n.
103 W.Jackson Blvd.,Erwin,NC,ERWIN,NC 28339
o. n.
Physical Address,City,and Zip -
21.REMARKS _ IL
HARNETT _
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.338288 N -78.67749 W /- �.�� 1/12/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or OTempomry By signing this form,I hereby certify that the wells)was(were)constructed in accordance uuh
15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
Ifthis is a repair fill out known well construction information and explain the nature of
the repair under-21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you
can submit one.form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17.0 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3(_200'and 2@100 J construction to the following:
10.Static water level below top of casing: 12.37 (g,) Division of Water Resources,Information Processing Unit,
1/'water level is above casing,use" " 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b.For Iniection Welts ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of this form within 30 days of
12.Well construction method: HSA completion of well construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells:
Also submit one copy of this form%s itlim 30 days of completion of well
13b.Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

N
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Ago
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_ SB-01 MW-5
p i
p� MW-2D
Gp� P SW-5
MW-07
MW-4
LEGEND
Soil Boring
® Monitoring Well
T e1I
( YP )
OMonitoring Well
(Type III)
© Active Potable
Water Supply Well
Approximate Location
of Former LISTS
(filled with concrete)
Parcel Boundary :•u e:E axa, • - , Earthstar Geographics,CNES/Airbus DS
SDA,USA -, er RID, IGN and the GIS User Community
NOTE: Well and UST locations were obtained from previous
reports prepared by other consultants and are approximate. 40 20 0 40 80
IMMMMMMMOMMINI Feet
PROJECT TITLE FIGURE
FOUR POINT GROCERY
ATLIN 5830 GOLDSBORO ROAD SITE MAP
CWADE, NC 1
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BVICHECKED BY
11660 220312 JAN 2022 AS SHOWN KMCIBJA

CATLIN
WELL LOG Engineers and Scientists
z2ozz7 SHEET 1 OF 1
PROJECT NO.: 220227 STATE: NC CouNTY: HARNETT LOCATION: ERWIN
PROJECT: EUS VILLAGE OPEN AIR MARKET LOGGED BY: O. Da nes WELL ID:
DRILLER: Austin Fowler MW-06R
NORTHING: 30703131 EASTING: 31600347 CREW: D.T._Chalmers
SYSTEM: NCSP NAD 83 USft BORING LOCATION: -3 feet north of MW-6 _ T.O.C.ELEV.: 99.27
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DT_W: 12.4 TOTAL DEPTH: 17.0
START DATE: 12/14/21 END DATE: 12/14/21 124 HOUR DTW: NM WELL DEPTH: 17.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 1 0.5ftj 0.5ft 1 0.5e (PPm) s c DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.3 0.0
0.0 0.5 (SM)-Brown SILTY F.SAND 98.8 0.0a 0.5
3 4 MW06R (CL)-Brown LEAN CLAY w/Trace SAND e
5 e 1.3 (0-2) D
u) t.s
2.0
5.0 5.0 94.3
(CL)-Gray and Red Mottled CLAY w/Med.Plastidty
N.
s 0.4 D
14
8.0 _ 91.3
----------
(SC)-Brown-Red CLAYEY SAND
of
oa
00
v
10.0 <V U)
,
4 9 0.9 D
10
(SW)-Tan Well Graded SAND,Faint HCO
�r
s'!
15.0
1 2 0.9 Sat. jf
5
17.0 V 17.0 82.3 17.0 17.0
BORING TERMINATED AT ELEVATION 82.3 ft in well
graded SAND
i
Concrete Bentonite Pellets E3#2 Medium Sand